1
|
Talbot S, Zordan R, Sasanelli F, Sun M. Preoperative quadriceps malalignment is associated with poor outcomes after knee replacement which are avoided by external rotation of the femoral component. Knee Surg Sports Traumatol Arthrosc 2025; 33:1418-1427. [PMID: 39666776 PMCID: PMC11948163 DOI: 10.1002/ksa.12544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2024] [Revised: 11/03/2024] [Accepted: 11/04/2024] [Indexed: 12/14/2024]
Abstract
PURPOSE Lateralisation of the proximal apex of the quadriceps tendon relative to the mechanical axis or external rotation relative to the femoral shaft can be accurately measured and is strongly associated with patella maltracking. The aim of this study was to first assess the association between preoperative quadriceps tendon alignment (QTA) and the patient-reported outcomes (PROMs) of total knee replacement, and second, determine the influence of component position on outcomes in patients with preoperative quadriceps tendon malalignment (QTM). METHODS A retrospective analysis of prospectively collected data was performed. All patients had preoperative and postoperative CT scans performed. PROMs were collected preoperatively and at 1 year postoperatively. QTA was measured by the quadriceps tendon axial angle (QTAx). The preoperative and postoperative coronal and axial alignment were measured. Femoral component rotation was measured relative to the preoperative posterior condyles. RESULTS Analysis was conducted on 388 cases and the mean preoperative QTAx was 6.2° externally rotated (standard deviation 12.0°). QTM (QTAx > 14°) was identified in 76 (19.8%) patients. The diagnosis of QTM was associated with reduced patient outcomes including Forgotten Joint Score (60.2 vs. 51.2, p = 0.008), EuroQol Visual Analogue Scale (81.3 vs. 75.7, p = 0.009), KOOS-12 (80.3 vs. 73.3, p = 0.001) and reduced PASS percentages for all KOOS subscales. In patients with preoperative QTM, femoral component external rotation >2° was associated with improved PROMs when compared to patients with <2° of femoral rotation. This included a clinically significant difference in the improvement of KOOS-12 (11.7 points, p = 0.013) and improved PASS percentages in all KOOS subscales. There was no association between coronal alignment or tibial axial alignment and outcomes. CONCLUSIONS Quadriceps malalignment is a common cause for poorer patient outcomes following total knee replacement. This can be avoided by externally rotating the femoral component to accommodate the deformity in the extensor mechanism. LEVEL OF EVIDENCE Level III, case-control study.
Collapse
Affiliation(s)
- Simon Talbot
- Department of Orthopaedic SurgeryWestern HealthMelbourneAustralia
| | - Rachel Zordan
- Faculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleVictoriaAustralia
- Education and LearningSt. Vincent's HospitalMelbourneVictoriaAustralia
| | | | - Matthew Sun
- Department of Orthopaedic SurgeryWestern HealthMelbourneAustralia
| |
Collapse
|
2
|
Pangaud C, Siboni R, Gonzalez JF, Argenson JN, Seil R, Froidefond P, Mouton C, Micicoi G. Restoring the Preoperative Phenotype According to the Coronal Plane Alignment of the Knee Classification After Total Knee Arthroplasty Leads to Better Functional Results. J Arthroplasty 2024; 39:2970-2976. [PMID: 38880407 DOI: 10.1016/j.arth.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 06/05/2024] [Accepted: 06/10/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND Mechanical alignment after total knee arthroplasty (TKA) is still widely used in the surgical community, but the alignment finally obtained by conventional techniques remains uncertain. The recent Coronal Plane Alignment of the Knee (CPAK) classification distinguishes 9 knee phenotypes according to constitutional alignment and joint line obliquity (JLO). The aim of this study was to assess the phenotypes of osteoarthritic patients before and after TKA using mechanical alignment and to analyze the influence of CPAK restoration on functional outcomes. METHODS This retrospective multicenter study included 178 TKAs with a minimum follow-up of 2 years. Patients were operated on using a conventional technique with the goal of neutral mechanical alignment. The CPAK grade (1 to 9), considering the arithmetic Hip-Knee-Ankle angle (aHKA) and the JLO, was determined before and after TKA. Functional results were assessed using the following patient-reported outcome measures: Knee Injury and Osteoarthritis Outcome Score, the Simple Knee Value, and the Forgotten Joint Score. RESULTS A true neutral mechanical alignment was obtained in only 37.1%. Isolated restoration of JLO was found in 31.4%, and isolated restoration of the aHKA in 44.9%. Exact restoration of the CPAK phenotype was found in 14.6%. Restoration of the CPAK grade was associated with an improvement in the "daily living": 79.2 ± 5.3 versus 62.5 ± 2.3 (R2 = 0.05, P < .05) and "Quality of life" Knee Injury and Osteoarthritis Outcome Score subscales: 73.8 ± 5.0 versus 62.9 ± 2.2 (R2 = 0.02, P < .05). CONCLUSIONS This study shows that few neutral mechanical alignments are finally obtained after TKA by conventional technique. A major number of patients present a postoperative modification of their constitutional phenotype. Functional results at 2 years of follow-up appear to be improved by the restoration of the CPAK phenotype, JLO, and aHKA. LEVEL OF CLINICAL ART EVIDENCE III, Retrospective Cohort Study.
Collapse
Affiliation(s)
- Corentin Pangaud
- Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, Marseille, France
| | - Renaud Siboni
- Department of Orthopaedic Surgery, Reims Teaching Hospital, Hôpital Maison Blanche, Reims, France
| | - Jean-François Gonzalez
- iULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, University Côte d'Azur, UR2CA, Nice, France
| | - Jean-Noël Argenson
- Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, Marseille, France
| | - Romain Seil
- Sports Clinic, Centre Hospitalier de Luxembourg - Clinique d'Eich, Luxembourg, Luxembourg
| | - Pablo Froidefond
- iULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, University Côte d'Azur, UR2CA, Nice, France
| | - Caroline Mouton
- Sports Clinic, Centre Hospitalier de Luxembourg - Clinique d'Eich, Luxembourg, Luxembourg
| | - Grégoire Micicoi
- iULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, University Côte d'Azur, UR2CA, Nice, France
| |
Collapse
|
3
|
Pamuk Ç, Moralar Ü, Gök Ü. Femoral Component Malrotation Following Total Knee Arthroplasty in the Presence of Hypoplasia: Is the Orthopedic Surgeon Aware? Cureus 2024; 16:e75488. [PMID: 39791099 PMCID: PMC11717382 DOI: 10.7759/cureus.75488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2024] [Indexed: 01/12/2025] Open
Abstract
Background This study hypothesizes that patients with femoral condylar hypoplasia who undergo total knee arthroplasty (TKA) may experience femoral component malrotation and that the surgeon performing the operation may not notice it. The aim is to measure the rotational alignment of the femoral components and assess the functional outcomes in these patients. Materials and methods Between December 2018 and December 2022, a total of 96 knees from 80 patients were evaluated. The patients were divided into two groups: one with femoral condylar hypoplasia and one without. Rotational changes and functional outcomes were assessed and compared. Results The study included 24 patients, 12 in Group 1 and 12 in Group 2. The demographic characteristics of the patients were homogeneous. The duration of knee prostheses ranged from two to four years. Femoral condylar hypoplasia was detected in 15% of all patients. All patients with hypoplasia had femoral components in varying degrees of internal rotation. There was no significant difference in functional scores between the two groups. Conclusions The rotation of the femoral component in TKA using the posterior condylar axis is affected by deformities in the condyles. In patients with lateral condylar hypoplasia, using the standard method inevitably results in internal rotation of the femoral component.
Collapse
Affiliation(s)
- Çağdaş Pamuk
- Orthopaedics and Traumatology, Silivri Anadolu Special Hospital, Istanbul, TUR
| | - Ülker Moralar
- Orthopaedics and Traumatology, Silivri Anadolu Special Hospital, Istanbul, TUR
| | - Ümit Gök
- Orthopaedics and Traumatology, Kocaeli State Hospital, Kocaeli, TUR
| |
Collapse
|
4
|
Ollivier B, Wakelin E, Plaskos C, Vandenneucker H, Luyckx T. Widening of tibial resection boundaries increases the rate of femoral component valgus and internal rotation in functionally aligned TKA. Knee Surg Sports Traumatol Arthrosc 2024; 32:953-962. [PMID: 38444096 DOI: 10.1002/ksa.12118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/12/2024] [Accepted: 02/15/2024] [Indexed: 03/07/2024]
Abstract
PURPOSE The purpose of this study was to investigate the influence of increasing the tibial boundaries in functional alignment on femoral component orientation in total knee arthroplasty (TKA). METHODS A retrospective review of a database of robotic-assisted TKAs using a digital joint tensioning device was performed (BalanceBot®; Corin). A total of 692 TKAs with correctable deformity were included. Functional alignment with a tibia-first balancing technique was simulated by performing an anatomic tibial resection to recreate the native medial proximal tibial angle within certain boundaries (A, 87-90°; B, 86-90°; C, 84-92°), while accounting for wear. After balancing the knee, the resulting amount of femoral component outliers in the coronal and axial plane was calculated for each group and correlated to the coronal plane alignment of the knee (CPAK) classification. RESULTS The proportion of knees with high femoral component varus (>96°) or valgus (<87°) alignment increased from 24.5% (n = 170) in group A to 26.5% (n = 183) in group B and 34.2% (n = 237) in group C (p < 0.05). Similarly, more knees with high femoral component external rotation (>6°) or internal rotation (>3°) were identified in group C (33.4%, n = 231) than in group B (23.7%, n = 164) and A (18.4%, n = 127) (p < 0.05). There was a statistically significant (p < 0.01) overall increase in knees with both femoral component valgus <87° and internal rotation >3° from group A (4.0%, n = 28) to B (7.7%, n = 53) and C (15.8%, n = 109), with CPAK type I and II showing a 12.9- and 2.9-fold increase, respectively. CONCLUSION Extending the tibial boundaries when using functional alignment with a tibia-first balancing technique in TKA leads to a statistically significant higher percentage of knees with a valgus lateral distal femoral angle < 87° and >3° internal rotation of the femoral component, especially in CPAK type I and II. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Britt Ollivier
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Hilde Vandenneucker
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Thomas Luyckx
- Department of Orthopaedic Surgery, AZ Delta, Roeselare, Belgium
| |
Collapse
|
5
|
Sterneder CM, Faschingbauer M, Haralambiev L, Kasparek MF, Boettner F. Why Kinematic Alignment Makes Little Sense in Valgus Osteoarthritis of the Knee: A Narrative Review. J Clin Med 2024; 13:1302. [PMID: 38592153 PMCID: PMC10932440 DOI: 10.3390/jcm13051302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 04/10/2024] Open
Abstract
There is a debate about the best alignment strategies in total knee arthroplasty (TKA). Mechanical alignment (MA) targets in combination with necessary soft tissue releases are the gold standard for TKA in end-stage valgus osteoarthritis. Some authors propagate kinematic alignment (KA) with the aim of restoring the patient's native alignment and minimizing the need for soft tissue releases. Our previous studies showed that MA with standardized soft tissue release produces reproducible results, and that the preoperative phenotype does not influence the results of patients with valgus osteoarthritis. These data suggest that there is no functional advantage to preserving valgus alignment in patients with valgus osteoarthritis. Many patients with valgus osteoarthritis present with a compromised medial collateral ligament and leaving the knee in valgus could increase the risk of secondary instability. The current literature supports MA TKA with soft tissue release as the gold standard. While using more sophisticated enabling technologies like robotic surgery might allow for aiming for very slight (1-2°) valgus alignment on the femoral side, any valgus alignment outside this range should be avoided. This review paper summarizes our current knowledge on the surgical techniques of TKA in patients with valgus osteoarthritis.
Collapse
Affiliation(s)
- Christian Manuel Sterneder
- Adult Reconstruction and Joint Replacement Department, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Martin Faschingbauer
- Department of Orthopedic Surgery, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Lyubomir Haralambiev
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany
| | - Maximilian F. Kasparek
- Department of Orthopedics, Evangelisches Krankenhaus, Hans-Sachs Gasse 10-12, 1180 Vienna, Austria
| | - Friedrich Boettner
- Adult Reconstruction and Joint Replacement Department, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| |
Collapse
|
6
|
Ollivier B, Vandenneucker H, Vermue H, Luyckx T. A robotic-assisted simulation of kinematic alignment in TKA leads to excessive valgus and internal rotation in valgus knees. Knee Surg Sports Traumatol Arthrosc 2023; 31:4747-4754. [PMID: 37464100 DOI: 10.1007/s00167-023-07504-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 07/03/2023] [Indexed: 07/20/2023]
Abstract
PURPOSE Strategies to further improve patient satisfaction after total knee arthroplasty include the introduction of new alignment philosophies and more precise instruments such as navigation and robotics. The aim of this study was to investigate the effect of a combination of image-based robotic assistance and the use of modern alignment strategies on the resulting joint line obliquity as well as femoral component rotation and to compare this between varus, neutral and valgus knees. METHODS This retrospective study included 200 patients who received a robotic-assisted total knee arthroplasty (MAKO®, Stryker) using functional alignment between 2018 and 2020. The patients were divided into a varus (103 patients), neutral (57 patients) and valgus (40 patients) group. The intraoperatively recorded bone cuts and resulting joint line obliquity were identified and compared to values obtained with a robotic computer simulation of kinematic alignment. RESULTS The mean femoral coronal alignment of the varus, neutral and valgus group, respectively, equalled 0.5° (± 1.1°), 1.1° (± 0.8°) and 1.6° (± 0.7°) of valgus with functional alignment and 2.1° (± 2.1°), 4.1° (± 1.7°) and 6.2° (± 1.7°) of valgus with kinematic alignment. The mean femoral axial alignment of the valgus group resulted in 0.8° (± 2.0°) of internal rotation with functional alignment and 3.9° (± 2.8°) of internal rotation with kinematic alignment. Overall, 186 knees (93%) could be balanced while respecting certain safe zones by using functional alignment as opposed to 54 knees (27% and none in the valgus group) when applying kinematic alignment. Kinematic alignment led to a combination of femoral component valgus and internal rotation of more than 3° in 22 valgus knees (55%), 10 neutral knees (18%) and 3 varus knees (3%) compared to none in each group when applying functional alignment with safe zones. CONCLUSIONS Robotic-assisted kinematic alignment leads to a combination of excessive valgus and internal rotation of the femoral component in valgus and to a lesser extent also in neutral knees when compared with functional alignment. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Britt Ollivier
- Department of Orthopaedics, University Hospitals Leuven, Herestraat 49, 3000, Louvain, Belgium.
| | - Hilde Vandenneucker
- Department of Orthopaedics, University Hospitals Leuven, Herestraat 49, 3000, Louvain, Belgium
- Department of Development and Regeneration, KU Leuven, University of Leuven, 3000, Louvain, Belgium
| | - Hannes Vermue
- Department of Orthopaedic Surgery, Ghent University Hospital, Ghent, Belgium
| | - Thomas Luyckx
- Department of Orthopaedic Surgery, AZ Delta, Roeselare, Belgium
| |
Collapse
|